Articles: Medical Records
Top Ten Ways to Evaluate Chronologies
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Chronologies
may be prepared by a legal nurse consultant to achieve many
objectives. For example, a chronology may intend to focus
on precise timing of events, correlate several factors,
define deviations from the standards of care related to
events, compare the observations of different providers,
or contrast deposition testimony with the events recorded
in the medical record. The top ten ways to evaluate the
quality of a chronology are as follows:
1. Is
the font easy to read? Times New Roman or Arial are two
fonts that are commonly used and easy to read.
2. Is
there a header at the top of the page?
3. Is
there light shading to the title row to set it off?
4. Are
the dates consistently formatted? For example, the chronology
should either use numbers, such as 1/25/05 or words, such
as January 25, 2005 but not both formats within the same
document.
5. Is
the time consistently formatted? Many people find military
time confusing and prefer that military time is translated
into AM and PM for ease of understanding.
6. Are
entries written in complete sentences?
7. Are
medical abbreviations spelled out the first time they are
used? For example, the sentence may say, “The physician
ordered MTX (Methotrexate) 2.5 mg six per day.”
8. When
there is an extensive amount of abbreviations used in a
chronology or medical summary, is there an appendix of all
of the abbreviations in alphabetical order for use by the
reader?
9. If
a word can not be deciphered, does the chronology indicate
this by using ___ or ??? (can not decipher)?
10.
Has the document been thoroughly proofread? Look for errors
in dates, in referring to the sex of the patient, and for
words that the spell checker will gloss over because they
are correctly spelled but wrong within the context of the
sentence.
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